Professional Documents
Culture Documents
ELEMENT 4
Learning Outcomes:
4.1. Discuss common methods and indicators used to monitor the effectiveness of
management systems
4.2. Explain why and how incidents should be investigated, recorded and reported
4.3. Explain what an audit is and why and how it is used to evaluate a management
system
4.4. Explain why and how regular reviews of health and safety performance are
needed
In some cases the countries laws may determine the Chemicals- correct storage and usage, compliance to
frequency. PPE.
Inspection and audit findings may suggest a higher Electrical- proper usage of portable tools, use of
frequency. protective devices.
Previous accident history and results of investigations. Environment- adequate lighting, noise and dust
controls and space.
Complaints from workers.
Vehicles- segregation of pedestrians, pedestrian
Risk assessments may suggest Inspections
crossing zones, vehicle parking areas.
Tools Required for Inspection - The
Action Plan for the Issues Identified:
Checklist:
Post inspection there should be arrangements to rectify
Checklists are good tools to ensure the systematic and
the problems that may have been identified during the
correct inspection of the workplace. The following are the
inspection. The problems identified should be prioritized
merits of using the checklist:
and the same should be followed up until the controls are
implemented.
are compliant. But safety sampling cannot replace 100% Lessons learnt from a single incident or
inspection. It goes without saying that somebody had Lessons learnt from incidents as a whole that has
to do the 100% inspection and only to ensure that this happened, say in the last three years.
Data can be converted into trends which can tell the
organization whether the numbers of incidents are
showing an upward or a downward trend or
This is done to learn from past incidences and prevent it Evaluation of Performance by Looking at
from happening in the future. The reports generated from the Enforcement Action:
reactive monitoring denotes the failures of the systems
The number of enforcement actions over the last several
and ineffectiveness of the control measures
years can also be converted into trends so as to analyze
Reactive monitoring examines the following to measure whether it is rising and if yes to find out the reasons for the
health and safety performance same. The fines issued by courts are also worth analyzing.
Accident data Evaluation of the Performance by Looking
Ill health data at the Civil Claims:
Absenteeism data Workers or others affected by the organizations activities
Claims records can approach the civil court against the employer to
Number of complaints reported claim for compensation. Organizations may also track the
Prosecutions number of civil claims year on year and the total amounts
paid to compare their performance reactively.
Enforcement notices
Evaluation of Performance by using Why lessons need to be learnt from
Incident Data Statistics: beneficial and adverse events.
The data on above reactive methods can be analyzed from: What are Beneficial and Adverse Events?
Organizations with positive culture are always striving The Difference between Leading and
to improve their health and safety performance. The
Lagging Indicators
steps thus taken may result in the safety performance to
improve, like for e.g. a reduction in reportable accidents,
Sr.
or a decrease in compensation payments as a result of Leading indicator Lagging indicator
No.
reduced incidents and claims etc. These events which lead
to improved performance are known as beneficial events. 1 A leading indicator is Lagging indicators are
While adverse events are those that lead to deterioration proactive in nature. measurements that
of the health and safety performance. For e.g. an increase They include safety include data from the
in ill health or a large number of fire incidents. initiatives or reported past. They include
activities, with the goal of incidents and accidents
The Lessons learned from both beneficial and adverse preventing unfavourable statistics.
events is the learning gained from the process that is events before they
applied. happen.
Each failure or success needs to be analysed, so that
what has been done correctly and what has been not 2 Leading indicators are Lagging indicators
is known to the organization. generated as a result are generated as a 04
of active monitoring result of reactive
Beneficial events will give the confidence to the
activities like safety monitoring activities
management to replicate the processes that lead to
inspections, preventive like measuring hours
such benefits all throughout the organization. For e.g.
maintenance etc. lost due to reportable
if the organization finds that the implementation of
injuries.
a new fire checklist has drastically brought down the
number of fire incidents, then the same may be taken 3 Leading Indicators can Examples of Lagging
up by all the departments. include: Indicators:
Similarly, adverse events are something which needs
Number and type Injury Frequency
to be investigated and the root causes needs to be
of Safety Trainings and Severity
evaluated. The learning’s from such events and the
completed vs planned Lost Workdays
ways to prevent it should be communicated across
the organization so that it does not repeat again. Results of Reportable
Behavioural Audits incidents
Organizations understand that they will benefit
from better knowledge of accidents if they, in turn, Results of Safety Employees
commit to improve their approaches to investigation, Audits compensation cost
including the way these generate recommendations Number of Toolbox Chemical releases
and reports. The consequence should be lessons Talks done vs planned
being learned, improvements made, fewer accidents Participation in Safety
and so reduction in losses. Committee
Lessons learnt need not be only from events within Equipment/Machinery
the organization but also from adverse and beneficial Maintenance vs
incidents outside the organization. planned
Organizations, thus take advantage of the key learning Hazard Identification
opportunities given by both adverse and beneficial events. & Risk Assessments
In fact, it is a key feature of the P-D-C-A cycle which leads
to continual improvement. 4 Leading indicators will The results of the
help to improve safety lagging indicators
through awareness will prove to the
and prevention and will management that the
show stakeholders that steps taken to improve
the company is taking occupational health
proactive steps to achieve and safety is actually
excellence in safety. working.
Observation:
The scene of the incident needs to be approached and
physical evidence needs to be gathered, investigators may
observe for ex; a patch of oil or a broken tool or a tripped
off circuit breaker etc. These will be vital clues and aid
finding out the root cause of the incident.
Interview:
In a minimal level investigation, the relevant
supervisor will look into the circumstances of the
There may be one or several witnesses to an incident. 04
Interviewing these witnesses provides with substantial
event and try to learn any lessons which will prevent
clues as to what caused the incident. Witnesses need to
future occurrences.\
be interviewed at the appropriate time, some witnesses
A low-level investigation will involve a short
may be in shock and may not be able to respond to
investigation by the relevant supervisor or line manager
queries adequately- this needs to be considered by the
into the circumstances and immediate, underlying and
investigators.
root causes of the adverse event, to try to prevent a
recurrence and to learn any general lessons. Following is the technique to be followed while conducting
a witness interview:
A medium-level investigation will involve a more
detailed investigation by the relevant supervisor Interview to be carried out in a quiet room away
or line manager, the health and safety adviser and from the accident spot, so that there can be proper
employee representatives and will look for the interaction with minimum distractions.
immediate, underlying and root causes. The interviewer should then introduce himself, and
A high-level investigation will involve a team- clear the purpose of the interview as something of
based investigation, involving supervisors or line a fact finding mission, rather than a fault finding
managers, health and safety advisers and employee mission. Emphasis should be laid out on the fact that
representatives. It will be carried out under the the interview is important so as to find out the cause
supervision of senior management or directors and will of the incident and avoid it from happening again.
look for the immediate, underlying, and root causes. The interview is to be recorded and signed at the end
Basic Incident Investigation Steps: of the session as a record.
The interview should be carried out using open ended
Before an incident investigation can start, the following
questions like ‘What’, ‘where’, ‘why’ etc. This is to
things needs to be considered:
prevent putting words into the witnesses’ mouth and
1. Gathering the information allow him to openly express his opinion.
2. Analysing the information The interviewer should keep an open mind and not
jump into conclusions.
3. Identifying risk control measures
End the interview by thanking the witness.
4. The action plan and its implementation
Documentation:
Step 1: Gathering the Information
Records and documentation will have to be referred so
Information can be gathered by looking at the following
as to substantiate the physical and verbal evidence with
three things:
written records. The records could be varied and exhaustive
Observation. (depends upon the type of accident and the depth of
Interviews. investigation). In general the following documents may be
Documentation. checked and examined:
The relevant policies of an unauthorized access aisle, not looking where he’s
Employee training records going, and heads towards a fire exit – a short cut to the
Maintenance records car park.
Sickness and absenteeism records The forklift truck driver sees the man at the last minute
Risk assessments and brakes hard, but skids on a patch of oil left by a leaking
Safe system of work forklift. He comes to an abrupt stop and the load falls onto the
warehouse operative, breaking his arm and bruising his leg.
Site plans and layout
Active monitoring records In this example the immediate causes are:
This as the name suggests is the immediate reason for the Rushing to get the job done
cause of the accident. Let’s take that an operator hurt his Speed limiter removed
finger while operating machinery. This would have been Lack of maintenance or inspection
caused by a guard not present or the guard removed.
Taking a short cut
The immediate causes are the result of ‘unsafe acts’ and
‘unsafe conditions’. In this case the unsafe act is removal Leaving work early
of the guard, and the unsafe condition would be guard not The root causes are:
provided in the first place itself.
Lack of supervision
Underlying Causes: Work pressures
These are the causes which are behind the immediate Poor customs and practices
causes. These could be like time pressures to complete the
task, not enough training or lack of maintenance. Step 3: Identifying Risk Control Measures
Control measures now need to be identified to remedy
Root Causes:
the situation. These measures should take care of both
These would normally point towards management the immediate and root causes. These control measures
deficiencies like no policy for training, no preventive should be well thought of for
maintenance of the machines, poor work practices.
No control measures in place or if so not used
Let’s now take an example of an accident and try to find
Prevent any wrong measures been implemented and
out the root causes:
thereby loss of time, cost and effort
You’re the manager of a distribution depot. It’s Friday
Combinations of the above.
afternoon, close to the end of the working day.
Each possible risk control measure should be evaluated for:
One of your warehouse operatives has had enough for
the day and decides to pack up early. Meanwhile, in the Their ability to prevent recurrences
warehouse one of your forklift truck drivers, who’s equally Whether they are practical
keen to finish his work, is driving his truck loaded with
Whether they will be used
boxes of paint. The forklift truck turns a corner and heads
Whether they will remain effective
at speed along the aisle towards the loading bay.
It will be important to consider whether similar risks exist
At that very moment, the warehouse operative comes out
elsewhere in the premises or on another site.
Step 4: The Action Plan and its Date and time of the incident
Date and time of the incident. Some of the barriers of incident reporting could include:
Location of the incident. No reporting policy in place.
Details of the injured person/ persons involved. A work culture of not reporting.
Details of injury sustained. Workers not aware that reporting of incidents is part
Description of the activity carried out the time. of their roles and responsibilities.
Drawings or photographs used to convey information There is blame culture in the organization, workers
on the scene. are afraid of disciplinary measures or of reprimand.
Immediate and underlying/ root causes of the Filling of the forms are too hard or takes too long.
incident. There is peer pressure that prevents reporting.
Assessments of any breaches of legislation. Once reported there is poor management response.
Details of witnesses and witness statements. Some may not report so as to prevent the
Recommended corrective action, with suggested departmental statistics from been affected which
may then further impact the earnings in the form of
costs, responsibilities and time scales.
incentives.
Estimation of the cost implications for the
Internally an incident may have to be notified to a range
organization.
of personnel, the more dangerous the incident the
How occupational accidents and diseases are more higher up it will be have to be reported. Generally
recorded and notified by the organisation following are the personnel who would be notified about
(as per ILO Code of Practice – chapters 4–7) the incident:
When an incident happens, it needs to be recorded and The top management.
reported. An incident would require to be reported both The HR and personnel department.
Internally within the organization and The health and safety specialist.
ISO 45001 defines audit as “a systematic, independent Examines documents Checks the workplace
and documented process for obtaining audit evidence Examines procedures Checks records
and evaluating it objectively to determine the extent Interviews workers Usually quick
to which the audit criteria are fulfilled.”
Verifies standards Lower cost
It is normally a lengthy process carried out by a trained Checks the workplace May only require basic
auditor, often someone from outside the organisation, Can be a long process competence
looking at the strengths and weaknesses of the May be Part of an audit
Usually expensive
organisation by using questionnaire.
Requires a high level of Done by a team
competence (Manager, Safety Adv.
Worker Rep)
Done by Trained Auditor
Internal Less expensive. Auditors may Information gathering - Normally an auditor would
audits not notice ask for a wide variety of documents which they would
Auditors already
certain issues. study upfront so they can prepare for the audit.
familiar with the
workplace and Auditors may Competency of the Auditor:
what is practicable not have good An audit can be done by a
for the industry. knowledge single person or a group
Can see changes of industry or of people, nevertheless
since last audit. legal standards. the auditors need to be
Improves Auditors may competent to conduct
ownership of issues not possess the audit. A competent
found. auditing skills auditor would be
so may need someone who has the
Builds competence
training. relevant certification, has
internally.
Auditors experience of conducting
Workforce may be
are not similar audits and has
more at ease.
independent so good knowledge of the companies’ processes. The above
Familiarity with competence is required for both internal as well as
may be subject
workforce and external auditors.
to internal
individuals.
influence. During the Audit:
The Audit Stages: An audit would begin on the designated day at the
designated time with an opening meeting. At this meeting
The process of audits involves several stages. Though
both the auditors and the auditees will be present and
there are different types of audits but most would follow
after the customary introductions, the auditors would
the following typical process:
announce the scope and extent of the audit and the
Pre- audit Preparations: schedule for the audit which is agreed mutually.
Paperwork or
documentation – the records
would indicate how well
the HSMS is working in the
organization. It would also
indicate to potential gaps.
This happens before an audit starts, and the following
needs to be defined upfront. Typically, an auditor may look at the following
documents to gain evidence of conformity.
The scope of audit- which will tell us what needs to be
– Health and safety policy.
audited
– Risk assessments and safe systems of work.
The area of the audit- the departments in which this
– Training records.
audit needs to be conducted.
– Minutes of safety committee meetings.
The extent of the audit- whether a comprehensive
audit, companywide or selective audit, covering a few – Maintenance records and details of failures.
departments. – Active monitoring records.
Who will be required - auditors will require a wide – Reactive monitoring records.
variety of personnel with whom they would require to – Emergency arrangements and mock drill records.
conduct interviews, also the auditors would require – Inspection reports by insurance agencies.
escorts who will accompany them in their visits to the – Outputs of regulator visits.
workplace.
– Records of any worker complaints.
Interviews: An auditor would interview the workers The auditors will give a verbal feedback as to what their
and managers of each department audited to main observations were and give a list of the improvements
understand how well the policies of the organization are required. The auditors would then follow up their verbal
understood at each level and whether they know their report with a written audit report which will in detail
roles and responsibilities towards health and safety. speak about the recommendations for improvements and
Observation: An auditor would take a round of the the timescales with priorities. An audit report may list a
department audited and observe the behaviour of the number of findings as follows.
workers and also to verify the correct implementation Major non-conformance: These are significant issues
of the SSOWs. which needs immediate attention. It would generally
point out to legal issues or major failures in the HSMS
Selection of Staff
in avoiding accidents. In ISO terms, these would
If audits are to be carried out internally, organisations mean denial of certification or even withdrawal of an
should be mindful of the fact that, very often, the results already awarded certificate.
of the audit may appear to be critical of the organisations Minor non- conformance: These are issues which are
and/or individual performance. This can lead to feelings of less serious and would generally do not point to any
resentment or even violence towards the auditor. When major weaknesses in the HSMS. These would require
selecting the people to carry out the audit employers 04
corrective action to be taken in a set period of time.
should be sure that the auditor is sufficiently strong of They would not cause a failure in the system.
mind to deal with these situations. It is important when
Observations: Auditors may put forward their
carrying out internal audits that the auditor is impartial; this
opinions on certain issues pertaining to the HSMS.
will usually mean that the auditor does not audit a function
These may or may not be implemented by the
of the organisation that they have responsibility for.
organization.
Determine cause to prevent recurrence The number of incidents within the period of
Identify weaknesses in management systems discussion would be taken up and ascertained
whether it is within the set limits and whether
Identify weaknesses in risk assessment
the trends are encouraging or otherwise.
Demonstrate management commitment
– Absence and sickness data: This would help in
Comply with country’s legal requirements
understanding whether the sickness is because
Collect data to establish losses of occupational related diseases or otherwise.
Provide information for Civil/Criminal actions Absence caused by workplace related stress
Provide information to insurance company could also be reviewed.
To meet the requirements of shareholders and Quality assurance reports: In this the company’s
stakeholders rejection and rework rates could be discussed
and even the customer complaints. This helps the
By ensuring that a cycle of continuous review takes place
company perform the role in the supply chain.
at all levels at desired frequencies, the following purposes
are achieved: Audit reports: Both internal and external audit
reports will be discussed and major, minor non
The management keeps on continuously measuring
conformities whether closed or yet to be closed
its performance.
will be reviewed. Any worthwhile suggestions by
It constantly updates their performance by comparing the auditors can also be taken up and decided on
the set targets vs the achieved. implementation.
It helps the management know whether enough is Monitoring data/ records/ reports: Various
been done to achieve the targets or more needs to be survey reports could be presented. For e.g. if dust
done. is considered to be problem for the organization,
It helps the management meet the commitments then the dust survey results could be presented and
set towards both their internal and external stake discussed.
holders. External communications and complaints: Issues
It demonstrates commitment of the management raised by the enforcement agencies or people living in
towards continual improvement and thus boosts the vicinity could be discussed.
morale of the workmen and aid in the creation of Consultation: Issues discussed in the safety
positive health and safety culture. committee meeting can be summarized.
Objectives met: A wide range of objectives set at
What the review should consider:
the planning stage can be discussed. Objectives could
A wide variety of issues may be considered during the be checked for achievement or the gaps could be
review: discussed and further course of action decided to
achieve the same within the set period.
Pending actions from previous reviews:
The previous reviews would have a range of Legal and best practice developments: New
recommendations which would have been converted national and international laws may have been passed
into action plans. Whether the targets set in the and could require organizations to implement them
action plan is achieved or not can also be reviewed. within the set time frame. These could be reviewed
and plans to implement them could be frozen during
Legal compliance: Any legal compliance still pending
the review.
to be achieved should be reviewed and regularly
followed up for closure. Reporting on Health and Safety
Findings of active monitoring: The findings of safety Performance:
inspections/ surveys/ tours and sampling will feed into
Review results on health and safety performance should
the review which help the organization understand its
be communicated to the senior management level. This is
compliance with the set standards.
especially useful to enable all of senior management to
Reactive monitoring data such as:
Understand the existing workplace scenario and
– Accident and incident data: This is a major
necessary initiatives to be taken
performance indicator for the organization
and would always form part of set targets. Determine whether the health and safety
management system elements are in place and
Summary
Positive health and safety culture of the organization can be achieved by proper monitoring of the health and safety
management system
In general, health and safety performance of the organisation is monitored by two methods. They are
– Active (Proactive monitoring)
– Reactive monitoring
Active (Proactive) monitoring – Evaluating health and safety standards before the occurrence of unwanted event. It
includes
– Safety inspections
– Safety tour
– Safety sampling
Active monitoring gathers information in the following ways
– Documentation – Examine records, reports and documents
– Interview – Communicate with people to get views and opinions
– Observation – Watching people’s behaviour
The following are some of the examples to derive standard of performance in an organisation
– Check health and safety training imparted to the workers as per the training calendar
– Monitor housekeeping activities in different zones again a set checklist
– Ensure safety inspections are happening as per the schedule
– Make sure workers are undergoing medical surveillance regularly
Methods of active monitoring
– Safety Inspection
It is a regular and scheduled activity that is carried out in comparison with accepted performance standards
It involves straightforward observation of a workplace, activities, and equipment to identify hazards
It is usually carried out by a manager, employee representative and Safety Advisor
Types of safety inspections
Routine inspection Determines if general standards of health and safety are acceptable or if corrective
action is necessary
Statutory inspection Performed by a competent person to fulfill a legal requirement
Periodic Inspection This is to ensure that the plant and machinery are maintained properly
Pre-use-checks To ensure the equipment or system is in good condition and safe to operate before
operation
Systematic inspections focus on four Ps for active monitoring of health and safety performance.
Types of P’s Areas to be inspected
Plant Work equipment, machinery and vehicles
Premises Workplace and its environment
People People’s working method and behaviour
Procedures Safe system of work, permit to work
Allocating specific responsibility is essential for each type of inspection. This should be based on the relevancy and
competency of the individuals E.g: Pre-use inspection is done by the operators themselves, while monitoring the
behaviour of the workers is done by supervisors
The person carrying out an inspection should have the necessary
– Relevant training, knowledge and experience
– Certification to a specific standard
Analysing the database of reported accidents and incidents helps to identify trends in WSH and identify hotspot areas
(particularly those with high accident records) for enhancing the overall safety of the organisation
Accident incidence rate (AIR) is used to compare organisation’s safety performance against a pre-defined standard.
Following is the formula
AIR = (Number of accidents in the given period / the average number of people in the given period) x 1000.
Generally accepted near misses greatly outnumber accidents and can therefore produce more data from which a
greater understanding of the deficiencies in management systems can be identified and rectified
Total number of enforcement actions and civil claims are also constitutes for measuring the safety performance of the
organisation.
The investigation and analysis of work-related accidents and incidents forms an essential part of managing health and
safety
When an incident happens, it is important on the part of the organization to record it correctly and investigate it to
avoid a recurrence
Lessons need to be learnt from beneficial and adverse events because of the following reasons
– The Lessons learned from both beneficial and adverse events is the learning gained from the process that is
applied.
– Each failure or success needs to be analysed, so that what has been done correctly and what has been not is known
to the organization.
– Beneficial events will give the confidence to the management to replicate the processes that lead to such benefits
all throughout the organization.
– Similarly, adverse events are something which needs to be investigated and the root causes needs to be evaluated.
The learning’s from such events and the ways to prevent it should be communicated across the organization so
that it does not repeat again.
The following are the basic steps that can be followed for carrying out an effective accident investigation:
– Gathering the information - Information can be gathered by the following three things
Observation
Interviews
Documentation
– Analyzing the information. – Gathered information needs to be analyzed to find out the causes of the incident.
Each incident report as well as a set of incident reports will present to the management of an organization with
invaluable data which will help them in its analysis and help them in managing the prevention of incidents even better
Finally all these reporting, recording and analysis of the incidents should culminate into lesson learnt, which can then
translate into awareness amongst the workers and overall health and safety improvement.
ISO 45001 defines audit as “a systematic, independent and documented process for obtaining audit evidence and evaluating
it objectively to determine the extent to which the audit criteria are fulfilled.”
The scope and purpose of the audit is to verify that
− Organization has an appropriate health and safety management system
− Whether the implementation is done correctly with appropriate risk controls in place.
− Results obtained through implementation of the system matches with the goals set by the organization
Health and Safety Management Systems should be audited because of the following reasons
– Positive:
To verify that
– Process audit
This type of audit verifies that processes are working within established limits. It evaluates an operation or method
against predetermined instructions or standards to measure conformance to these standards and the effectiveness
of the instructions.
– System audit
An audit conducted on a management system. It can be described as a documented activity performed to verify,
by examination and evaluation of objective evidence, that applicable elements of the system are appropriate
and effective and have been developed, documented, and implemented in accordance and in conjunction with
specified requirements
Before commencement of the audit process, the following things should be ensured.
The scope of audit It should specify what needs to be audited. It may be company policy, health and safety
policy and so on
The area of the audit Information about the departments or sites needs to be audited
The extent of the Whether a comprehensive audit, companywide or selective audit, covering a few
audit departments
Who will be required Auditors will require a wide variety of personnel with whom they would require to conduct
interviews
Information Normally an auditor would ask for a wide variety of documents which they would study
gathering upfront so they can prepare for the audit
− When selecting the people to carry out the audit, employers should be sure that the auditor is sufficiently
strong of mind to deal with any kind of situations
During the audit, the auditor would gather factual information by looking at the following evidences
Paperwork or documentation Records would indicate how well the HSMS is working in the organization.
Typical record includes
– Health and safety policy
– Risk assessments and safe systems of work
– Training records
– Minutes of safety committee meetings
– Maintenance records and details of failures
– Active monitoring records
– Reactive monitoring records
Interviews Interact with workers and managers to ensure how the policies of the
organization are understood and implemented
Observation Observe behavior of workers and system of work to identify and analyse 04
problematic safety and other issues
It is the responsibility of the organisation to implement all the recommendations and corrective actions recommended
in the health and safety audits
Depending upon the audit report, the management team needs to come out with an action plan by assigning
responsibilities and approving resources to achieve them in the desired time.
Monitor and analyse of activities related to organization’s operations like business structure, employee behavior is
called internal audit. It is normally carried out by competent person of the organization.
Advantages and disadvantages of internal audits
Advantages Disadvantages
Less expensive. Auditors are not independent so may be subject to internal influence
Auditors already familiar with the Auditors may not notice certain issues
workplace and its processes and
operations
Organization’s performance standards and health and safety policy is audited by third party is called external audit
Advantages and disadvantages of external audits
Advantages Disadvantages
No internal influence Expensive
Have wider experience auditing different Time-consuming
types of workplace